Unit 2- WK6 - Procedural Coding III and Medical Necessity and Skilled Care

Question 1

What are modifiers ?

Answer 1

-modifiers are used to ensure proper reimbursement ( 59, GP, KX, GA)

billing may need to be modified

Question 2

Explain the 59 modifier and give example:

Answer 2

-signifies to medicare that procedures were done separately from each other and reimbursement should be received for both codes

documentation must support them as separate and distinct procedures.

Question 3

What is a GP modifier and when is it used ?

Answer 3

used to indicate that PT services were provided

common in multiple therapy facilities

Question 4

What is the KX modifier and when would you use it ?

Answer 4

Used when services exceed medicare Part B threshold

tells medicare that PT is necessary, documentation must support.

Question 5

What is the GA modifier and when is it used ?

Answer 5

Notify payer that there is an ABN on file for a service that medicare won’t cover

allow biller to bill secondary insurance or patient

Question 6

A therapist must provide, direct one on one therapy for at least ________ minutes to receive reimbursement for a time based treatment code billed for a Medicare Part B beneficiary .

Answer 6

8 minutes

Question 7

Explain how many units you can bill for a treatment session.

Answer 7

First you add up how many total treatment minutes were spent then you divide by 15 and if number exceeds 8 minutes then you can bill another unit.

Question 8

The 8 minute rule is a Medicare Part B rule and not a requirement of all payers. Explain the Substantial Portion Methodology used by non-medicare insurers.

Answer 8

Must perform service for at least 8 minutes, then you can bill for that service.

Question 9

What qualifies for billable minutes ?

Answer 9

all the things you have to do to deliver intervention

patient assessment
patient’s response
instruction
answering patient questions

Question 10

What activites are non-billable minutes ?

Answer 10

unskilled prep time, unskilled clean up, rest perriods and other break times, supervision of independent patient, “rounding up”, documentation.

Question 11

Overbilling is an intentional tactic used to wrongfully obtain higher payments. Describe the 3 types of over billing:

Answer 11

Upcoding: charging for more costly services than were actually delivered.

Utilization abuse: scheduling extra visits or providing unnecessary services

Overcharging: the act of charging additional units of the services the therapist performed or tacking on codes for services not provided.

Question 12

What is the bottom line when it comess to coding and billing for PT services ?

Answer 12

provide medically necessary services specific to the patient’s treatment plan, and only bill for the services you actually provide.

Question 13

The social security act 1862 (A) (I) states: “ No payment may be made under Part A or Part B for any expenses incurred for items or services which are not __________________ for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Answer 13

reasonable and necessary

Question 14

Define skilled care.

Answer 14

When the knowledge, abilities, and clinical judgement of PT are necessary to safely and effectively furnish a recognized therapy service whose goal is for the improvement of an impairment, functional status, or slowing of deterioration.

Question 15

List the types of things a PT does, that is considered “ skilled therapy “

Answer 15

measurements, tests and interpretations, assessment, instruct/cue, device selection.

Question 16

Describe maintenance therapy.

Answer 16

Procedures required to maintain current function or to prevent or slow further deterioration

Question 17

When is a maintenance program considered “skilled” and covered by Medicare ?

Answer 17

creating program, patient instruction, period re-eval

Question 18

When is a maintenance program no longer covered by Medicare ?

Answer 18

when patient/caregiver independence is documented.

Question 19

What therapy services are not covered by Medicare ?

Answer 19

general exercise to promote overall fitness, diversion activities, services not in POC, services provided by unqualified staff.

Question 20

What do you need to include in your documentation to ensure that Medicare will cover the services you provided ?

Answer 20

service is reasonable and effective

Question 21

When supporting medical necessity what are the 3 things you must communicate.

Answer 21

a. services are consitent w/ nature and severity of illness, injury and medical needs

b. services are specific, safe and effective according to accepted medical practice

c. skilled therapy is needed to maintain or improve function or to slow deterioration

Question 22

Where do you document medical necessity and skilled care for evals and daily notes

Answer 22

evals; assessment portion

daily: objective and assessment portion

Question 23

Give an example of documenting medical necessity and skilled care for a PT eval.

Answer 23

TUG score indicates the patient is at a high risk for falls

Question 24

In documenting skilled care for Daily notes, what do you need to include:

Answer 24

a. type and level of skilled assistance given to patient

b. Type and amount of manual, visual, verbal cues, used to assist patient

c. why interventions were chosen and necessary

d. Intervention should correlate to goals

Question 25

What are the elements of the checklist to help ensure you have included everything in your documentation:

Answer 25

a. provide a brief assessment of the patients clients response to the intervention at every visit

b. do not use “ pt tolerated treatment well”

c. make sure documentation is not repetitive

d. reread documentation.